Barbara L. Leighton

Supplemental oxygen for the prevention of postcesarean infectious morbidity: a randomized controlled trial

OBJECTIVEnThe purpose of this study was to investigate whether supplemental oxygen during and for 2 hours after cesarean delivery reduces the incidence of postcesarean infectious morbidity.nnnSTUDY DESIGNnWe conducted a randomized, controlled trial from 2008-2010. Women who underwent cesarean delivery were randomly assigned to receive either 2 L of oxygen by nasal cannula during cesarean delivery only (standard care) or 10 L of oxygen by nonrebreather mask (intervention group) during and for 2 hours after cesarean delivery. Women who underwent scheduled or intrapartum cesarean delivery were eligible and were observed for 1 month after the procedure. The primary composite outcome was maternal infectious morbidity, which included endometritis and wound infection.nnnRESULTSnFive hundred eighty-five women were included in the final analysis. Infectious morbidity occurred in 8.8% of patients in the standard care group and in 12.2% of patients in the supplemental oxygen group. There was no significant difference in the rate of infectious morbidity between the standard care and intervention groups (relative risk, 1.4; 95% confidence interval, 0.9-2.3).nnnCONCLUSIONnSupplemental oxygen does not reduce the rate of postcesarean delivery infectious morbidity, including endometritis and wound infection.

Use of Recombinant Factor VIIa in Patients with Amniotic Fluid Embolism A Systematic Review of Case Reports

BACKGROUNDnPatients with amniotic fluid embolism (AFE) (major cardiac and pulmonary symptoms plus consumptive coagulopathy) have high circulating tissue factor concentrations. Recombinant factor VIIa (rVIIa) has been used to treat hemorrhage in AFE patients even though rVIIa can combine with circulating tissue factor and form intravascular clots. A systematic review was done of case reports from 2003 to 2009 of AFE patients with massive hemorrhage who were and were not treated with rVIIa to assess the thrombotic complication risk.nnnMETHODSnMEDLINE was searched for case reports of AFE patients receiving rVIIa (rVIIa cases) and of AFE patients who received surgery to control bleeding but no rVIIa (cohorts who did not receive rVIIa). Additional AFE case reports were obtained from the Food and Drug Administration, the Australian and New Zealand Haemostasis Registry, and scientific meeting abstracts. The risk of a negative outcome (permanent disability or death) in rVIIa cases versus cohorts who did not receive rVIIa was calculated using risk ratio and 95% confidence interval.nnnRESULTSnSixteen rVIIa cases and 28 cohorts were identified who did not receive rVIIa. All patients had surgery to control bleeding. Death, permanent disability, and full recovery occurred in 8, 6, and 2 rVIIa cases and 7, 4, and 17 cohorts who did not receive rVIIa (risk ratio 2.2, 95% CI 1.4-3.7 for death or permanent disability vs. full recovery).nnnCONCLUSIONnRecombinant factor VIIa cases had significantly worse outcomes than cohorts who did not receive rVIIa. It is recommended that rVIIa be used in AFE patients only when the hemorrhage cannot be stopped by massive blood component replacement.

Fentanyl-induced cough is a risk factor for postoperative nausea and vomiting

BACKGROUNDnPostoperative nausea and vomiting (PONV) and fentanyl-induced cough (FIC) are two common anaesthesia-related events, which seem to have common risk factors. In this prospective cohort study, we investigate whether patients who have FIC during induction of anaesthesia have an increased incidence of PONV.nnnMETHODSnWe studied adult non-smoking gynaecological surgical patients enrolled between July 1, 2011 and July 30, 2012. The presence of FIC during induction and the occurrence of PONV were recorded. Fentanyl-induced cough and other perioperative variables were subjected to multivariate analysis to determine the association between FIC and PONV.nnnRESULTSnAll 502 patients enrolled in this study had at least two risk factors for PONV, and 154 (31%) developed FIC. The incidence of PONV in the FIC group was higher than in the non-FIC group (56.5 vs 38.2%; P<0.0001). Multivariate logistic regression analysis found FIC to be a predictive risk factor for the development of PONV (adjusted odds ratio 2.08, 95% confidence interval 1.41-3.07).nnnCONCLUSIONSnNon-smoking women undergoing gynaecological surgery who develop FIC during induction of anaesthesia have a higher incidence of PONV.

Necrotizing fasciitis after cesarean delivery.

T HIS 27-yr-old patient (preoperative body mass index, 32 kg/m) presented 12 days after a repeat cesarean delivery. The patient complained of pain, swelling, and a 6 4-cm complex mass of bloodfilled bullae on her abdominal panniculus, 7 cm from her well-healed incision. She was afebrile and not diabetic. Her hemoglobin concentration was 8.3 g/dl; leukocyte count, 23,200/ml; and creatinine concentration, 3.9 mg/dl. Bleeding, not infection, was suspected; necrotizing fasciitis was not diagnosed until the computed tomographic scan was examined (fig.). Surgical debridement required removal of 75% of the panniculus. The patient went to intensive care intubated, on a phenylephrine infusion, with her open wound packed. She was discharged home with negative-pressure wound therapy. The wound healed completely, and the patient’s renal function normalized. Necrotizing fasciitis is a rapidly progressing, usually polymicrobial, infection of subcutaneous tissue. The infection can spread up to 2.5 cm/h, with minimal change in the overlying skin. Erythema, swelling, and severe pain are generally seen at presentation. Bullae and soft tissue gas (fig.) are late signs. Anemia, hyponatremia, hypoglycemia, and increased creatinine, C-reactive protein, and leukocyte count are laboratory risk indicators for necrotizing fasciitis. Magnetic resonance imaging or computed tomography can establish the diagnosis and guide the extensive surgical debridement. Obesity is a risk factor for postcesarean necrotizing fasciitis, which has an incidence of 2 per 1,000 cesarean deliveries. Because necrotizing fasciitis– associated mortality increases as the time to intervention lengthens, anesthesiologists can improve care for these patients by facilitating prompt surgical debridement.

Patient-Controlled Epidural Levobupivacaine with or without Fentanyl for Post-Cesarean Section Pain Relief

Purpose. The purpose of this study was to compare the analgesic properties of levobupivacaine with or without fentanyl for patient-controlled epidural analgesia after Cesarean section in a randomized, double-blinded study. Methods. We enrolled American Society of Anesthesiologists class I/II, full-term pregnant women at National Taiwan University Hospital who received patient-controlled epidural analgesia after Cesarean section between 2009 and 2010. Eighty women were randomly assigned into two groups. In group A, the 40 subjects received drug solutions made of 0.6u2009mg/ml levobupivacaine plus 2u2009mcg/ml fentanyl, and in group B the 40 subjects received 1u2009mg/ml levobupivacaine. Maintenance was self-administered boluses and a continuous background infusion. Results. There were no significant differences in the resting and dynamic pain scales and total volume of drug used between the two groups. Patient satisfaction was good in both groups. Conclusion. Our study showed that pure epidural levobupivacaine can provide comparative analgesic properties to the levobupivacaine-fentanyl combination after Cesarean section. Pure levobupivacaine may serve as an alternative pain control regimen to avoid opioid-related adverse events in parturients.

A first step in determining appropriate amounts of obstetric anesthesia work.

Ginosar, et al. describe a new performance indicator, the Obstetric Anesthesia Activity Index, to represent the current amount of obstetric anesthesia work done daily at each of 25 Israeli hospitals. The authors claim, correctly, that this index is a closer reflection of the anesthetic workload than simply looking at the number of deliveries at each hospital. However, the Obstetric Anesthesia Activity Index could easily be refined to reflect more closely the actual obstetric anesthesia workload by using the average cesarean delivery time for each hospital rather than one value for all hospitals. Although the authors state that they developed the Obstetric Anesthesia Activity Index out of concern for inadequate obstetric anesthesia manpower in Israel, they have not compared the Obstetric Anesthesia Activity Index with the size of the patient population or any measure of patient satisfaction or patient safety. In its current form, the Obstetric Anesthesia Activity Index describes the current work situation but does not evaluate the extent of the unmet need for additional anesthesia providers. Despite these shortcomings, the Obstetric Anesthesia Activity Index is an important first step in developing a tool to assess unmet obstetric anesthesia needs.